The ticklish balancing act: Resident rights vs. care quality
Dr. Eleanor Barbera
You know the scenario: A resident wants to eat donuts, but it will send her blood sugar skyrocketing. The staff members aren't sure whether to let her indulge as part of person-centered care or to insist on a sugar-free alternative so that they're not out of compliance with her care plan.
A recent study by Parker et. al examined the staff-perceived conflicts between providing services that are consonant with resident-centered care and those that are in compliance with regulations and the rights of other residents, referred to in their research as “care quality.” They made recommendations based on their findings to ease these conflicts.
They interviewed nursing home staff at 12 different Veterans Administration facilities, including senior leaders, middle managers and direct care staff, asking them questions about care such as, “Is resident-centered care implementation competing with other facility goals?”
All of the nursing homes found some level of conflict between resident-centered care and quality.
The three main areas of divergence were in 1) resident preferences versus medical care, such as issues around dietary compliance, 2) resident preferences and the rights or safety of others, such as someone disrobing in common areas, and 3) “limits on staff ability to respond, related to either time or regulations.”
The first type of conflict was the most common by far, with issues not only around dietary compliance, but also around situations such as when the resident wants to go outside to smoke but weather extremes make it physically unsafe, or residents who are in danger of falling but want to assume the risk and walk unaided.
The second area of friction was related to social or emotional health, such as roommate conflicts. Others related to concerns about physical health, such as when a resident with an infection wants to engage in activities that could put the health of others at risk.
A complicating factor in these instances was the need to explain these situations to family members who might feel that the limits being put on a loved one are not consonant with resident-centered care.
In the third category of conflict, staff members found it difficult to accommodate resident preferences when they were short-staffed, especially at mealtimes when there were multiple demands on their time.
The authors of the study made several recommendations to help minimize these conflicts in the approach to care.
• Determine how each resident feels about the balance of quality of life versus long-term survival. Assess and document the risks involved in their choices and the efforts of team members to mitigate the risks. Helpful tools and examples can be found in this Ideas Institute document, “A Process for Care Planning for Resident Choice.” McKnight's blogger The Real Nurse Jackie wrote more about the document here.
• Educate staff members about how to manage situations where residents make requests that contradict health recommendations, using skills practice as part of the training process.
• Assess roommate compatibility with regard to sleeping patterns and other preferences prior to roommate assignment. In a prior column, I offered this guide based on my experiences with typical roommate conflicts.
• Consider getting a better sense of resident preferences upon admission through the use of the Preferences for Everyday Living Inventory (PELI), or the PELI questions in MDS 3.0 section F. My recommendation would be the latter because it's easier to meet a reasonable number of resident preferences. To ask questions about preferences the facility is unable to satisfy is setting unattainable expectations on the part of residents and their families that can lead to disappointment, anger and possibly litigation.
• Evaluate the need for explicitly different policies for short-term residents whose goals are for medical stabilization, physical rehabilitation and discharge versus long-term residents who desire to maintain some personal choices within an institution they'll live in for the rest of their lives.
I'll add a few more suggestions of my own:
• Work with treatment teams to find ways to accommodate resident preferences while not overburdening staff, such as aides covering for each other while they're on breaks or adjusting how meals are served so that foods are hotter/colder as needed. Rethink systems rather than expecting staff members to work around ineffective procedures.
• Train staff members so that they're comfortable speaking to families about how the facility makes decisions about residents' choices when they're not in alignment with general practices, or so they know who to refer family members to for such discussions.
• Consider a psychology referral for residents with preferences that diverge from care quality since some of their choices may reflect difficulty adjusting to institutional life, depression or longstanding interpersonal problems.
Balancing the rights and desires of residents with the need of the facility to avoid citation and litigation can be tricky, but as Nurse Jackie points out based on this study, “the implementation of culture change is actually associated with fewer health-related and quality of life-related deficiencies.”
Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident's Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.